Provider Demographics
NPI:1558453951
Name:TOWN OF PHELPS
Entity type:Organization
Organization Name:TOWN OF PHELPS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EMS SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SELIN
Authorized Official - Suffix:
Authorized Official - Credentials:EMT-INTERMEDIATE TEC
Authorized Official - Phone:715-545-3538
Mailing Address - Street 1:PO BOX 72140
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-7340
Mailing Address - Country:US
Mailing Address - Phone:262-375-9610
Mailing Address - Fax:262-375-9608
Practice Address - Street 1:4499 TOWN HALL ROAD
Practice Address - Street 2:
Practice Address - City:PHELPS
Practice Address - State:WI
Practice Address - Zip Code:54554-9273
Practice Address - Country:US
Practice Address - Phone:715-545-3538
Practice Address - Fax:715-545-3538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60013743416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41356300Medicaid
WI52D0985331OtherCLIA NUMBER
WI6001374OtherSTATE LICENSE #
WI6001374OtherWI DEPT OF HEALTH SERVICES
WI52D0985331OtherCLIA NUMBER